Pseudo-outbreak of Acinetobacter lwoffii infection in a tertiary care center in Thailand.

We describe a pseudo-outbreak of Acinetobacter lwoffii infection that was recognized early. The pseudo-outbreak involved 16 patients and occurred 3.5 months after the GNS-506 Vitek automated system was introduced in the microbiology laboratory. Prompt confirmation of incomplete use of the automated system's algorithm as the point source of the misidentified A. lwoffii clinical isolates averted a full outbreak investigation and excess use of infection control resources.     

Risk factors and outcomes of influenza A (H3N2) pneumonia in an area where avian influenza (H5N1) is endemic.

We conducted a cohort study to identify the risks and outcomes of influenza A (H3N2) pneumonia. Of the 145 patients studied, 10 (7%) had influenza A pneumonia. Logistic regression identified multiple comorbidities (P<.001) and diarrhea at the initial presentation (P=.001) as associated risks. Infection with influenza A (P=.01) and receipt of inadequate antimicrobial therapy (P=.005) were predictors of mortality.     

Inflammatory mediators and the destruction of bone

Bone is remodelled by the coordinated actions of osteoclasts and osteoblasts. Cellular remodelling occurs in discrete packets of bone, and is regulated by local cytokines produced in the environment of the remodelling cells. These cytokines are secreted by immune cells and by bone cells. In addition, some growth regulatory factors are incorporated into the noncollagenous bone matrix and are released in an active form when bone is stimulated to resorb. Complex interactions between these cytokines and their target cells are responsible for the normal delicate balance between bone resorption and bone formation, and disorders of bone loss are due to imbalances between the rates of resorption and formation.     

A preliminary report on a new hydraulic sphincter for controlling urinary incontinence

A new pressure-regulated artificial urinary sphincter (AUS) has been developed which overcomes many of the deficiencies of earlier devices. This implantable AUS comprises a circular occluder cuff and the means to inflate and deflate through a pressure-regulated valve. The device is made from medical-grade silicone rubber and filled with radio-opaque isotonic fluid. A few days before surgery the implant is coated on the outside with an antibiotic-loaded silicone rubber solution. Tests have shown that the regulated pressure was very easily adjusted in situ by injecting or withdrawing the hydraulic fluid through a hypodermic needle penetrating a self-sealing filling port. When set, the regulated pressure remained very stable. The mechanism by which cuff pressure was increased to overcome stress incontinence worked well. Of the five earlier devices (AUS Mk I) implanted, none has survived without mechanical failure. The two latest implants (Mk II), which were rigorously tested for defects before implantation, have been more successful.     

A technique for total substitution of the lower urinary tract without the use of a prosthesis

A technique is described for total replacement of the lower urinary tract in women in which a pedicled labial skin tube is created and anastomosed to a substitution cystoplasty with a submucosal tunnelled type of "anti-reflux" anastomosis which provides a continence mechanism. The patients thereafter void by intermittent self-catheterisation. This technique has been used in 6 women as part of total pelvic reconstruction for vesico-vagino-rectal fistula following radical radiotherapy, with or without a Wertheim's hysterectomy, for carcinoma of the cervix. A similar technique using a pedicled preputial/penile skin tube has been used in 2 men following a cystoprostato-urethrectomy for transitional cell carcinoma of the bladder.     

The treatment of sphincter strictures

A group of 25 patients with strictures of the membranous urethra following transurethral resection of the prostate (TURP) were investigated and treated initially by careful urethral dilatation. This controlled the stricture in 14 patients, 6 of whom continued with occasional dilatation or self-catheterisation to maintain control; 8 required an artificial urinary sphincter (AUS) and 2 required a "clam" ileocystoplasty for detrusor instability. Eleven had persistent or recurrent strictures requiring urethroplasty. Nine underwent bulbo-prostatic anastomotic urethroplasty, 4 with simultaneous bladder neck reconstruction and 5 with subsequent implantation of an AUS; 2 had a preputial patch urethroplasty with subsequent implantation of an AUS. Four of the 9 patients with a urethroplasty and an AUS are satisfactory, 1 developed a recurrent stricture and 2 developed erosions. Two of those with a bulbo-prostatic anastomosis and bladder neck reconstruction are satisfactory and 2 are incontinent. These results were compared with those of 18 other patients who underwent bladder neck reconstruction and 12 who had a urethroplasty in conjunction with an AUS for reasons other than a post-TURP sphincter stricture. The success rate of bladder neck reconstruction was 55% and the success rate of urethroplasty in conjunction with an AUS was 83%, but the main complication of AUS implantation, erosion, was a more serious problem than failure of bladder neck reconstruction. However, the much higher success rate makes AUS implantation a more satisfactory procedure. Surgery should be avoided if at all possible and reliance placed on urethral dilatation.     

EEG correlates of the development of infant joint attention skills

The development of the capacity for social attention coordination, or "joint attention," is a major milestone of infancy. Data from a recent study of handicapped infants have raised the hypothesis that the tendency to initiate bids for joint attention may reflect processes associated with the frontal cortex to a greater extent than other forms of infant attention coordination (R. Caplan et al., 1993). This hypothesis was examined in a longitudinal study of 32 normally developing infants. The results indicated that EEG data at 14 months indicative of left frontal, as well as left and right central cortical activity, was associated with the tendency to initiate joint attention bids (IJA) at 14 and 18 months. In contrast, a pattern of left parietal activation and right parietal deactivation at 14 months was associated with the development of the capacity to respond to the joint attention bids (RJA) of others at 14 and 18 months. These results were interpreted to be consistent with a general anterior-posterior model of attention development (M. Posner & S. Petersen, 1990). The implications of these results for current conceptualizations of joint attention development, as well as for understanding the disturbance of joint attention skill development in autism are discussed.     

The unstable bladder

The unstable bladder is a common clinical problem of uncertain etiology. Current in vitro studies of unstable human detrusor samples show differences in behavior and response to pharmacologic agents from normal detrusor. The fundamental urodynamic abnormality is the occurrence of involuntary detrusor contractions, which cause the cardinal symptom of urgency. The incidence of other symptoms is determined by the functional bladder capacity and the patient's ability to resist the unstable contractions. Having excluded outflow obstruction as a causative or associated factor, empirical treatment may reasonably be started on the basis of the findings of a 48-hour voided volume chart, reserving full urodynamic investigation for patients who fail to respond to treatment as expected. For those with minimal urodynamic dysfunction, bladder drill is the treatment of choice; when this fails or is inappropriate, drug treatment with oxybutynin is indicated, supplemented by other drugs when appropriate. When these standard conservative measures fail, then transvesical injection of the pelvic plexuses with phenol gives worthwhile results and is a trivial procedure. If this fails, and in men in whom the phenol procedure is contraindicated, "clam" ileocystoplasty is usually if not always curative.     

"Clam" ileocystoplasty for the treatment of refractory urge incontinence

Forty patients with refractory urge incontinence were treated by "clam" ileocystoplasty. Thirty patients were cured of their symptoms and are voiding spontaneously, six were cured of their symptoms and are on clean intermittent self-catheterisation and four had their symptoms significantly improved by the operation. Bladder compliance is usually improved by the operation and detrusor instability is either abolished or reduced to an insignificant level, but voiding dysfunction is a common post-operative problem and must be identified and treated.